[image:1 align:left caption:true]Last month, the Centers for Disease Control and Prevention (CDC) released provisional data indicating that the country's overdose crisis peaked in late 2017 and actually declined by 5.1 percent between then and late 2018. While that is long-awaited good news, it's not great news: The annual number of drug overdose deaths was still more than 68,000, and that number is still more than a third higher than in 2014, when the overdose epidemic was already well underway.

The fever may have broken, but the patient is still in critical condition. And there is one bit of data in the CDC report that is definitely not good news: While overall overdose deaths finally began to decline, overdose deaths involving stimulants were on the increase. For cocaine, the death toll started rising in about 2012; for psychostimulants (overwhelmingly methamphetamine), the climb began a couple of years earlier.

But the new data show a dramatic uptick in overdose deaths with stimulant involvement last year. Fatal overdoses where cocaine was mentioned were up 34 percent and those where methamphetamine was involved were up 37 percent. That's more than 14,000 people dying with cocaine in their systems and more than 10,000 dying with meth in their systems.

What is driving this spike in stimulant-involved overdose deaths? Some of it can be attributed to rising use levels for cocaine and meth, which can in turn be linked to increased supplies. Meth seizures were up dramatically last year and recent DEA reports suggest that cocaine availability has increased steadily since 2012, particularly in the south and east coast of the US. The UN Office of Drugs and Crime suggests that cocaine production and manufacture are at the highest rates ever recorded.

"There is some research to suggest that we are seeing slightly higher rates of recent cocaine and methamphetamine use compared to rates of use just a few years ago," said Sheila Vakharia, PhD, a researcher with the Drug Policy Alliance (DPA). "But increased rates of use do not always mean increased rates of addiction or overdose. Death rates are influenced by a variety of factors, including age of the user, the amount used, and other substances used, among other things."

They are also influenced by race, gender, and geographic location. A recent study looking at data from 2012 to 2015 and examining race and gender trends by drug found that white men had the highest rates of methamphetamine-involved overdose deaths more generally, while black men had highest rates of cocaine-involved overdose deaths. These racial differences persisted for women of each race as well, although their overdose rates were lower than the men in their racial groups.

"Methamphetamine-involved deaths are high on the West Coast and Midwest, while cocaine-involved deaths are high on the East Coast. We are actually seeing that in some Western states that methamphetamine is either the top drug involved in overdose deaths or among the top drugs included in overdose deaths," Vakharia noted.

"Based on the latest CDC data, Nevada’s overdose crisis has been driven by prescription opioids and methamphetamine for the past several years- in fact, methamphetamine has been the #1 drug involved in overdoses there since November 2016. Similarly, in November 2016, Oregon saw methamphetamine become the top drug involved in overdose deaths," she specified.

"Meanwhile, the East Coast is seeing the involvement of cocaine in overdoses increase as well. While no eastern state has cocaine driving their overdose crisis, places like DC are seeing fentanyl as the top driver of deaths followed by cocaine. Last year, while fentanyl contributed to the majority of overdose deaths, there were more cocaine-involved deaths than heroin or prescription opioids," Vakharia added.

It appears that it is not rising simulant use rates but the use of multiple substances that is largely driving the overall stimulant death toll upwards. A CDC report from May suggests that, from 2003 to 2017, almost three-quarters of cocaine-involved deaths involved an opioid while half of all methamphetamine involved deaths involved an opioid.

"Those CDC numbers are based on autopsy reports," said Daniel Raymond, deputy director of planning and policy for the Harm Reduction Coalition (HRC). "In a lot of cases, there are multiple drugs involved, and just because an overdose involves a stimulant, it doesn't mean it was caused by stimulants."

Overdose deaths caused by stimulants look different from those caused by opioids, Raymond noted: "Fatal stimulant overdoses come from strokes, seizures, heart attacks, and potentially overheating," he said. "It's not like an opioid overdose with respiratory depression," he said.

"Some of this may be more a reflection that we still have lots of people dying from opioid-related overdoses, and it's just that more of them are also taking meth or cocaine, but the primary cause of death is the respiratory depression associated with opioid overdoses. In a lot of the cocaine deaths, medical examiners are finding both cocaine and opioids."

"We are seeing that toxicology reports of people who died with stimulants in their systems also had fentanyl or other opioids in their system," DPA's Vakharia concurred. She then listed a number of possible explanations:

1. "This is accidental. Cross-contamination of a stimulant with an opioid like fentanyl could have been accidental and occurred during transport or packaging, and opioid-naïve stimulant users were accidentally exposed to opioid-contaminated stimulants."
2. "This is due to co-use of opioids and stimulants in the form of speedballs (with cocaine) or goofballs (with methamphetamine), where both are used together for the desired effect of immediately stimulating high, followed by the euphoria of the opioid."
3. "Stimulants are being willfully adulterated with opioids by suppliers/sellers, and stimulant users naïve to opioids are overdosing because they have no tolerance. (We at DPA dispute this theory, because it makes little sense why a seller would want to kill off a customer.)
4. "Someone might have used a stimulant and opioids at different times within the past few days, but their toxicology could be showing the recency of use."

What Is to Be Done?

The Drug Policy Alliance and the Harm Reduction Coalition have both released reports on the rise in stimulant-involved overdose deaths, Stimulant Use: Harm Reduction, Treatment, and Future Directions from the former and Cocaine, Speed, and "Overdose": What Should We Be Doing? from the latter. Raymond and Vakharia took a few minutes to address those topics, too.

"There is no naloxone for stimulant overdose," Raymond pointed out. To reduce those overdoses "is about developing harm reduction strategies and outreach specifically targeting stimulant users," he said. "We spend so much time focusing on the opioid overdose crisis that our messages are oriented toward that. If we want to start a conversation, we need to not just tack it onto the opioid messaging. Even if you're not an opioid user, we want to talk about symptoms and warning signs."

HRC has moved in that direction, said Raymond. "We did some work on stimulant overdoses, we talked to a lot of people who used stimulants, we put out a guide -- Stimulant "Overamping”"Basics -- and went with the terms people used. Using 'overamping' opened a space for conversation for people who didn't identify as heroin users. If you talk overamping instead of overdosing, stimulant users have had that experience of using too much. Part of it is really just listening to the people who use the drugs. In harm reduction, we learn from the people we work with."

"People who use stimulants need access to sterile equipment beyond syringes, since many stimulant users smoke, so we are talking about sterile smoking equipment like pipes and filters," Vakharia said. "We need to teach users how to stay safe while using -- make sure to take breaks for hydration and to eat, get enough rest. It is easy to lose track of time when you've been up for days and when you have no appetite. This also puts undue stress on your heart and can exacerbate health issues," she noted.

"For many people, we should also talk about distributing safer sex supplies, because many people engage in risky sexual practices while they are using," Vakharia continued. "We also need to educate users on the risks associated with mixing different classes of drugs and the impact it can have on your body, knowing your limits, keeping naloxone on hand in case you are using opioids too, and not using alone."

It's not just harm reduction that's needed, though. Other policy prescriptions could help reduce the toll.

"Medicaid expansion and policies to increase access to basic health care and mental health care, as well as substance use treatment can greatly improve the health and well-being of people who use all drugs," Vakharia said. "And whether opioids are a person's primary drug or not, expanding access to naloxone helps anyone who is using them. Similarly, expanding Good Samaritan laws that reduce barriers to calling 911 can only help."

And then there's not treating drug uses like criminals.

"Decriminalizing drugs and paraphernalia would be a huge step forward," said Vakharia. "We know that contact with the criminal justice system increases harms and also presents barriers to going into recovery, which impacts job prospects, the ability to find work, and things like that."

"Drug decriminalization is crucial," said Raymond. "Criminalization just makes everything worse. It makes people more fearful of seeking help, and ends up locking so many people up in ways such that when they leave jail or prison, they're even more vulnerable. All of our work in harm reduction takes place in this context of mass criminalization. That keeps us swimming against the tide."

This article was produced by Drug Reporter, a project of the Independent Media Institute.

The Drug Policy Alliance is a funder of both Drug Reporter and Drug War Chronicle.